Healthcare Provider Details

I. General information

NPI: 1407911894
Provider Name (Legal Business Name): TERESA MCCOLLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 08/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 CHANATE RD
SANTA ROSA CA
95404-1707
US

IV. Provider business mailing address

3333 CHANATE RD
SANTA ROSA CA
95404-1707
US

V. Phone/Fax

Practice location:
  • Phone: 707-565-4935
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number598932
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number1758
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: